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Surgical resection of renal cell carcinoma remains the mainstay for the management of patients who suffer from this disease. Five percent to 10% of renal cell carcinomas develop a tumor thrombus that propagates into the renal vein or the inferior vena cava. Radical nephrectomy and inferior vena cava thrombectomy can provide longstanding survival rates comparable to those for tumors confined to the renal parenchyma. In general the surgical approach is dictated by the cephalad extension of tumor thrombus. This article reviews the authors' experience with 243 patients who suffered from renal cell carcinoma with extension into the venous system with specific reference to the surgical techniques and the long-term outcomes.

When the need for urinary diversion arises, whether from carcinoma of the urinary tract, malfunction, or malformation, a decision must be made about the type of diversion to be performed. Currently, the patient and surgeon must decide on continent versus noncontinent versus neobladder and on the type of intestinal segment to be used. Not long ago noncontinent diversion was the only choice available, and for many patients, it remains the best choice. It is the fastest, the simplest to perform and to care for, and is associated with the least risk of long-term and short-term complications. A noncontinent diversion is, in essence, a disarticulated bowel segment to which the ureters are attached proximally and with a stoma distally. Any segment of ureter can be accommodated, from the renal pelvis to trigone, and any segment of bowel can form the conduit, although ileum and colon are associated with the fewest metabolic consequences.

SUMMARY Unfortunately, no randomized trials have compared PTRA. for renovascular hypertension with surgical or medical treatment. PTRA appears to be a safe and relatively simple procedure with complication rates lower than those of operation. The outcome of renal angioplasty depends on the type of stenosis. In all published series, the cure rates for fibromuscular disease are significantly higher than for atherosclerotic disease, and PTRA appears to be the procedure of choice in the treatment of hypertension in patients with fibromuscular disease. The role of renal angioplasty in patients with renovascular hypertension due to atherosclerotic diseases is uncertain. Most large published series describing the success of angioplasty in patients with atherosclerotic lesions have been highly selective, primarily including patients with focal stenotic lesions. Despite this selectivity, the cure rate has been only 19%. In completely unselected patients, atherosclerotic lesions are associated with a very high rate of technical failure, possibly as high as 60%.3 From the data available, focal isolated stenotic lesions of the renal artery due to atherosclerotic disease can be treated with a reasonable rate of success. The success rate in patients with bilateral disease, osteal stenosis, or total occlusion of the renal arteries appears to be very limited. In these patients, angioplasty should be attempted only when a surgical contraindication exists.

Fortunately, the incidence of serious bowel and conduit problems in the immediate postoperative period and within the first year after diversion is low (5 to 10 per cent). The ileal or colon conduit still serves as the standard method of urinary diversion in adults with pelvic malignancy. Prevention of these complications should truly begin in the preoperative period, and careful judgement should be used postoperatively so that no therapeutic option is undertaken too early. The goal in managing these complications is the preservation of renal function, the maintenance of longest possible amount of functioning bowel, and the absence of indwelling stents and tubes. Patience is needed, along with the maintenance of drainage, adequate nutrition, observation for and treatment of sepsis, and a careful delineation of the anatomic defects. These patients, with their high reoperative mortality rate (approximately 50 per cent), present one of the most intriguing and complicated challenges to the urologist. Using the principles outlined here, we have had only one death in 22 consecutive patients referred to the Lahey Clinic for the management of complex bowel and urinary tract complications following urinary diversion.

Surgery of the upper urinary tract and the retroperitoneal spaces is a constant invitation to potentially serious bleeding. An adequate well-organized exposure of the pathologic condition involved, detailed knowledge of the regional anatomy and its variations, careful gentle dissection of the major vessels, and a calm disposition of the surgeon are the critical factors in preventing intraoperative hemorrhage. Unexpected bleeding is at times unavoidable, and the urologic surgeon should have a well-prepared method for managing hemorrhage during each procedure. Temporary control with gauze packs, sponge sticks, or the surgeon's finger should be the initial step in the control of serious hemorrhage, and this will virtually stop most bleeding. The subsequent period should be used to communicate with the anesthesiologist, who must replace the blood already lost and forewarn the blood bank of future needs. The surgeon is obligated to improve exposure of the bleeding site, dissect out the vessel involved, obtain any additional necessary lighting and suction equipment, and call for a colleague to help secure the vascular rent while applying continued proximal and distal tamponade. Because serious intra-operative hemorrhage can be encountered by even the most skilled surgeon, consultation with an experienced colleague should be looked on as an integral part of the armamentarium for the optimal care of the urologic patient.

SUMMARY The ileocecal conduit and its antirefluxing component have functioned well and have prevented many of the upper-tract complications associated with other forms of diversion. Its future role remains to be determined. Today, continent forms of diversion, such as the Koch pouch and the continent ileocecal reservoir, are being studied and are becoming popular. A continent antirefluxing form of urinary diversion is the ideal we are striving to achieve.

Cushing's syndrome represents a constellation of symptoms of various origins. In most patients, detailed endocrinologic and radiologic testing will differentiate between Cushing's disease, adrenal adenoma, adrenal carcinoma, primary bilateral nodular hyperplasia, and ectopic corticotropin-producing tumors. Although adrenal surgery affords rapid and reliable remission in patients with Cushing's syndrome, it is associated with significant morbidity and mortality. Complications can be minimized by careful perioperative preparation. The indications for adrenal surgery for Cushing's disease have been altered radically by the success and low morbidity of transsphenoidal surgery. Total adrenalectomy is indicated in patients with bilateral nodular hyperplasia and should be considered for adults who have failed selective pituitary adenectomy or hypophysectomy and in whom ectopic corticotropin secretion has been unequivocally ruled out. At the Lahey Clinic, total adrenalectomy is performed through an anterior abdominal incision. Anterior approaches are especially indicated in those patients who require abdominal exploration for other intra-abdominal pathologic conditions that require surgery. Total adrenalectomy is indicated in the very rare patient who has Cushing's syndrome caused by ectopic corticotropin production when the patient is severely ill, a primary tumor is not found, and medical therapy fails or is poorly tolerated. Small adrenal tumors are best approached through a flank incision. Larger potentially malignant tumors should be approached through a thoracoabdominal incision.

The surgical techniques for the antirefluxing ileocecal conduit, particularly suited for urinary diversion, and for the add-on ileocecal loop, designed to salvage a malfunctioning ileal conduit, are outlined.

SUMMARY The clinical awareness of the various presentations of pheochromocytoma, along with newer monitoring and anesthetic techniques, has enabled early diagnosis and less fluctuation of blood pressure during operation. The use of meticulous surgical technique through the various incisions outlined in this article has made the excision of pheochromocytoma an expeditious operation and the accompanying hypertension surgically curable. Thus, pheochromocytoma is less likely to be a fatal lesion.